Browsing by Author "Hapangama, A."

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Achievements and challenges in psychiatric education and training in Sri Lanka
(Cambridge University Press, 2023) Hapangama, A.; Kuruppuarachchi, K.A.L.A.; Hanwella, R.
ABSTRACT: When compared with other Asian countries, psychiatric education and training in Sri Lanka has made significant developments during the past two decades, such as introducing psychiatry as a separate final year subject in the undergraduate medical curricula. However, further developments in psychiatric training in medical education are needed.
Assessing motivation to lose weight: the psychometric properties of the Sinhala version of University of Rhode Island Change Assessment (URICA) scale
(Sri Lanka Medical Association, 2023) Niriella, M.A.; de Silva, S.T.; Hapangama, A.; Baminiwatta, A.; Fernando, R.; Ediriweera, D.
INTRODUCTION: Weight reduction through lifestyle modifications is an important component in the management of various chronic diseases. The degree of motivation to change has been shown to predict outcomes in weight reduction interventions. Thus, the availability of a validated self-report tool assessing the degree of motivation for weight management would be useful for both clinical and research purposes in Sri Lanka. OBJECTIVES: To examine the structural validity and internal consistency of the URICA for weight management in a sample of Sri Lankan adults with chronic medical conditions. METHODS: Standard procedures for cross-cultural adaptation of a questionnaire were followed in translating the 32-item URICA into Sinhala. The Sinhala version was administered to 208 patients aged 18-60 years attending outpatient clinical services for non-disabling chronic medical diseases. Psychometric testing included confirmatory factor analysis and the assessment of internal consistency (Cronbach α). RESULTS: The commonly accepted four-factor structure of URICA reflecting Prochaska and Di Clemente’s transtheoretical model (pre-contemplation, contemplation, action and maintenance) showed good model fit, after the removal of four items from the pre-contemplation subscale due to inadequate factor loadings (<0.4). In line with theory, factor correlations indicated that the pre-contemplation factor was inversely correlated with the other three factors, while the other three factors were positively correlated with one another. All four subscales showed good internal consistency (Cronbach α ranging from 0.73 to 0.89). CONCLUSIONS: The Sinhala version of a modified 28-item URICA was found to have sound psychometric properties as a measure of motivation for weight management among Sinhala-speaking adult patient.
Attitudes toward prenatal diagnosis and termination of pregnancy for genetic disorders among healthcare workers in a selected setting in Sri Lanka
(Wiley, 2008) de Silva, D.C.; Jayawardana, P.; Hapangama, A.; Suraweera, E.G.D.N.; Ranjani, D.; Fernando, S.; Karunasena, C.; Jinadasa, S.
Awareness and attitudes regarding electroconvulsive therapy (ECT) among patients and caregivers at a psychiatry unit in a tertiary care hospital in Sri Lanka
(Sri Lanka College of Psychiatrists, 2020) Gunasekera, T.; Fernando, R.; Peris, M.U.P.K.; Kuruppuarachchi, K.A.L.A.; Hapangama, A.
INTRODUCTION: Electroconvulsive therapy (ECT) is a life-saving procedure in certain psychiatric conditions and is also extremely effective for treatment resistant psychiatric conditions. Despite the proven safety and efficacy there appears to be unease and stigma attached to ECT. Exploration about the awareness and attitudes regarding ECT among patients and caregivers can improve the practice of ECT. AIMS: The aim of this study was to describe awareness and attitudes about ECT among patients and their caregivers. METHODS: This was a descriptive cross-sectional study carried out among patients and caregivers attending psychiatric facilities at a tertiary care hospital in Sri Lanka, using an interviewer administered questionnaire. RESULTS: Out of 221 participants, 54% were caregivers. Among the participants, 65% thought that ECT is a treatment used for psychiatric disorders. There was no significant association between educational level and awareness about ECT (p>0.05). The most common source of knowledge about ECT was doctors (43%), but 69% felt doctors have not explained about ECT prior to treatment. Cognitive issues (46%) were the most commonly feared side effect; 5% thought ECT does not have a scientific basis and 20% felt it is an inhuman mode of treatment. Of those interviewed, 38% were of the opinion that they would receive ECT if recommended. CONCLUSIONS: Doctors were the most important source of information regarding ECT and a significant proportion of the participants knew that it is used in treating psychiatric disorders. Only a minority thought ECT didn’t have a scientific basis and a considerable proportion were willing to undergo ECT if recommended. Despite popular beliefs this cohort of participants appeared to have a favourable awareness about ECT. KEYWORDS: Electroconvulsive therapy, Awareness, Attitudes, Stigma
Awareness and usage patterns of substances among pre-clinical phase students at a Medical Faculty in Sri Lanka
(Sri Lanka Medical Association., 2019) Hapangama, A.; Fernando, R.; Pathmeswaran, A.; Kuruppuarachchi, K.A.L.A.
INTRODUCTION AND OBJECTIVES: Availability and usage patterns of psychoactive substances have changed worldwide. Knowledge about new trends of substance use is important for future generation of medical professionals to deliver appropriate treatment. Objective of the study was to determine the awareness and prevalence of substance use among pre- clinical phase medical students in a university in the Western Province, Sri Lanka. METHODS: A cross-sectional descriptive study was carried out using a self-administered questionnaire. RESULTS: Out of 162 students, 61.7% were female, 97.5% were between 20-25 years. 99% were aware of alcohol being a substance of abuse. 34% and 30% were not aware that heroin and cannabis were substances of abuse. Less than half of participants were aware of corex-D (44.4%), volatile substances (39.5%), and methamphetamines (32.7%). Figures for awareness about Psilocybin (9.9%), MDMA (8.6%), LSD (8%), GHB (4.3%), DXM (2.5%). Main sources of information regarding substances were peers and internet. 21% and 18 % of participants had used alcohol and betel respectively at least once while tobacco and corex-D was used among 7.4% and 6.2% respectively. 69% of substance users were male. Use of substances was significantly associated with male gender. CONCLUSION: Alarmingly majority of the participating pre-clinical phase students were not aware of the abuse potential of heroin and cannabis as well as of newer generation recreational drugs. Awareness regarding current trends and misuse potential of psychoactive substances and their consequences should be enhanced among medical students.
Awareness regarding electroconvulsive therapy (ECT) among service users at a tertiary care hospital
(Sri Lanka Medical Association, 2019) Hapangama, A.; Gunasekera, T.; Pieris, M.U.P.K.; Fernando, R.; Kuruppuarachchi, K.A.L.A.
INTRODUCTION & OBJECTIVES: ECT saves lives and is extremely effective in treatment resistant psychiatric conditions. Despite this there appear to be an unease and stigma attached to ECT. Exploration about the awareness regarding ECT among service users can improve the practice of ECT. Objective was to demonstrate awareness about ECT among services users at a tertiary care hospital. METHODS: Cross-sectional study carried among all consenting service users at a tertiary care Hospital in Sri Lanka using an interviewer administered questionnaire. RESULTS: Out of 221 participants, 54% were careers. 65% thought ECT is a treatment for psychiatric conditions while 58% and 19% thought ECT is used to violence in the absence of a mental illness and to punish opponents respectively. There was no-significant association between educational level and awareness about ECT (p>0.05). The commonest source of ECT was doctors (43%). Cognitive side effects (46%) and headache (59%) were the commonly feared side effects. 5% thought ECT doesn’t 't have a scientific basis-and 20% felt it is an inhuman mode of treatment. 38% felt they would receive ECT if recommended. CONCLUSION: Doctors were the commonest source of information regarding ECT and more than half of the participants knew it was used to treat a psychiatric condition. Surprisingly only a minority thought ECT didn't have scientific basis however 20% felt it was an inhumane mode of treatment. However, a considerable proportion were willing to undergo ECT if recommended. Despite popular beliefs this cohort of participants appeared to have a more favourable awareness about ECT.
Betel-quid use and its effects on symptoms of schizophrenia and extrapyramidal symptoms among a group of patients in a tertiary care hospital in Sri Lanka.
(Sri Lanka College of Psychiatrists, 2020) Isuru, A.; Ediriweera, D.; Pathmeswaran, A.; Embuldeniya, A.; Narammalage, H.; Warnakulasuriya, S.; Kuruppuarachchi, K.A.L.A.; Hapangama, A.
BACKGROUND: There is limited research regarding the prevalence of betel quid use and its effects on symptoms of patients with schizophrenia. Available studies suggest an association between betel chewing and positive symptoms among males with schizophrenia. AIMS: This study aimed to compare the prevalence of betel quid chewing between patients with and without mental illness, and to explore the association between betel quid use, symptoms of schizophrenia and side effects of psychotropic medication. METHODS: A cross sectional descriptive study was carried atoutpatient clinics at a tertiary care hospital in Sri Lanka. A structured interview schedule was administered to all participants. RESULTS: Out of 1000 participants, 20.9% chewed betel quid (95%CI: 18.4% - 23.4%). The rate of betel chewing among patients with and without a mental illness was 20.7% (95% CI: 17.0% - 24.4%) and 21.0% (95% CI: 17.6% - 24.5%) respectively and there was no significant difference between the two groups. There was no statistically significant difference between the occurrence of positive or negative symptoms and extra pyramidal side effects in patients with schizophrenia who did and did not chew betel. Female gender (p=0.004) and betel quid chewing (0.002) were associated with more anticholinergic side effects. CONCLUSIONS: There was no association between betel quid usage and the occurrence of positive or negative symptoms of schizophrenia or extra pyramidal side effects. KEYWORDS: Schizophrenia, Betel quid, Positive symptoms, Negative symptoms, Extra pyramidal side effects
A case of hypotension and heart rate changes on rechallenge with a low dose of clozapine with no apparent secondary cause
(Sri Lanka College of Psychiatrists, 2022) Harshini, M.L.; Fernando, A.I.W.; Abayawickrama, H.M.T.S.; Ikram, M.I.N.; Rajapakse, S.; Hapangama, A.
Clozapine is known to cause innocuous as well as severe and or fatal cardiovascular side effects. These side effects are commonly reported at the initiation of clozapine therapy. We report a patient who was stable on clozapine for several years but in whom we had to withhold clozapine for medical reasons and subsequently developed significant hypotension and heart rate changes when rechallenged with a small dose of clozapine.
COVID-19 pandemic and assessments of final year medical students in psychiatry: an innovative Sri Lankan experience
(Sri Lanka College of Psychiatrists, 2021) Hapangama, A.; Kuruppuarachchi, K.A.L.A.
No abstract available
Cross-cultural adaptation and validation of the Leibowitz Social Anxiety Scale (LSAS-SR) sinhala version
(Sri Lanka Medical Association, 2020) Hapangama, A.; Kuruppuarachchi, L. A.; de Silva, R.; Wickremasinghe, A.R.; Ravindran, A.; Williams, S. S.
No abstract available
Cross-cultural adaptation and validation of the Liebowitz Social Anxiety Scale (LSAS-SR) Tamil Version
(The Sri Lanka Medical Association, 2022) Hapangama, A.; Premaratne, I.; Thilaxshan, T.; Gadambanathan, T.; Wickremasinghe, R.
Background: Despite being the third most prevalent psychiatric disorder, social anxiety disorder remains under-diagnosed due to multiple reasons. Although many screening instruments are available in the English language, to date no instrument has been translated into Tamil. Objective: To translate and validate the Liebowitz Social Anxiety Scale (LSAS-SR) into Tamil among a group of Sri Lankan university students whose mother tongue is Tamil. Method: The process of translation and validation involved standard procedures. DSM- 5 was used as the gold standard to diagnose social anxiety disorder. As part of the psychometric study, test-retest reliability and analysis of items for internal consistency of the instrument were assessed. Results: A cut off of55.5had the optimum sensitivity and specificity for the Tamil version of the LSAS-SR. The Cronbach’s alpha between the avoidance subscaletotal and the fear subscale total was 0.860 while the figures for Cronbach’s alpha between the total score and fear subscale total score and the avoidance subscale total score were 0.880 and 0.855, respectively. The test- retest reliability correlation coefficients for the fear subscale, avoidance subscale and the total score were 0.890, 0.925 and 0.918, respectively (p<0.001 for all). Conclusions: The cut off score of 55.5had the optimum sensitivity and specificity for the LSAS-SR Tamil version. It had good internal consistency and test-retest reliability. Further studies will enable the assessment of the prevalence of social phobia and investigation of cultural and environmental factors associated with social phobia in Sri Lanka.
Cross-cultural validation of the Sinhalese version of the Liebowitz Social Anxiety Scale (LSAS-SR): study of the items and internal consistency
(Book of Abstracts, Annual Research Symposium 2014, 2014) Williams, S.; Kuruppuarachchi, K.A.L.A.; Hapangama, A.; Wickremasinghe, R.; Ravindran, A.
Background: Despite being the third most prevalent psychiatric disorder, social phobia remains to be under -diagnosed due to multiple reasons. Although many screening instruments are available in English language, up to date no instrument has been translated in to Sinhalese or its cultural relevance studied. Liebowitz Social Anxiety Scale(LSAS-SR) is one of the most widely used scales to screen for social phobia and it evaluates fear and avoidance symptoms associated with the above disorder.
Dextromethorphan abuse
(Sri Lanka Medical Association, 2008) Hapangama, A.; Kuruppuarachchi, K.A.L.A.
No Abstract Available
Ethno-psychopharmacology
(Royal College of Psychiatrists, 2008) Hapangama, A.; Kuruppuarachchi, K.A.L.A.
Headache: an important symptom possibly linked to white matter lesions in thalassaemia.
(Wiley-Blackwell, 2019) Premawardhena, A.; Ranawaka, U.; Pilapitiya, T.; Weerasinghe, G.; Hapangama, A.; Hettiarachchi, S.; Salvin, K.; Silva, I.; Hameed, N.; Weatherall, M.; Olivieri, N.; Weatherall, D.
Neurological manifestations are reported only occasionally in patients with thalassaemia and are given much less prominence than the complications related to anaemia and iron overload. White matter changes (WMCs) on magnetic resonance imaging (MRI) in patients with thalassaemia were first reported two decades ago but the significance of these lesions remains unclear. We studied the neurological and cognitive manifestations in 82 older patients with thalssaemia [25 Thalassaemia major (TM), 24 thalassaemia intermedia (TI) and 33 haemaglobin E β thalassaemia (EBT)] and 80 controls, and found that headaches were more common in thalassaemia patients (50/82, 61%) than in controls (18/80, 22·5%: P < 0·001). WMCs on MRI were found in 20/82 (24·3%) patients and 2/29 (6·9%) controls had (P = 0·078). WMC were more common among those with headaches (17/50: 34%) than in those without headache (3/32; 9·3%) (P = 0·023). WMCs were not associated with reduction of cognition. Nevertheless, cognition was lower in the TI and EBT groups compared with those with TM (P = 0·002). The association of headache with WMC in thalassaemia has not been reported before and warrants further study.
Impact of COVID-19 on the mental health of frontline and non-frontline healthcare workers in Sri Lanka
(The Sri Lanka Medical Association, 2021) Baminiwatta, A.; de Silva, S.; Hapangama, A.; Basnayake, K.; Abayaweera, C.; Kulasinghe, D.; Kaushalya, D.; Williams, S.
INTRODUCTION: Healthcare workers (HCWs) are at risk of mental health problems during a pandemic. Being stationed at the frontline or not may have implications on their mental health. OBJECTIVES: The aims of this study were to assess depression, anxiety and stress among HCWs, to explore differences between frontline and non-frontline workers, and to investigate associated factors. METHODS: In this cross-sectional study, frontline and non-frontline HCWs were recruited from a COVID-19 screening hospital in Sri Lanka. Mental health impact was assessed using Depression, Anxiety and Stress Scale (DASS-21). Sociodemographic data and perceptions of social and occupational circumstances were gathered. Categorical variables were analyzed using Chi square and logistic regression. Odds ratios were calculated for the effect of different perceptions on psychological morbidity. RESULTS: A total of 467 HCWs participated, comprising 244 (52.2%) frontline and 223 (47.8%) non-frontline workers, with female preponderance (n=341, 77%). Prevalence of depression, anxiety and stress among HCWs were 19.5%, 20.6%, 11.8%, respectively. Non-frontline group showed a higher prevalence of depression (27% vs. 11%, p<0.001), anxiety (27% vs. 14%, p=0.001) and stress (15% vs. 8%, p=0.026). Being married, having children, living with family and higher income were associated with better psychological outcomes. Perceived lack of personal protective equipment, inadequate support from hospital authorities, greater discrimination, and lack of training to cope with the situation predicted poor mental health outcomes, and non-frontline HCWs were more likely to hold such perceptions. CONCLUSION: Addressing factors leading to negative psychological outcomes in HCWs should be a key concern during this pandemic. KEYWORDS: COVID-19, Mental health, Hhealthcare workers, Frontline, Depression, Anxiety, Stress
Improving psychological well-being among healthcare workers during the COVID-19 pandemic with an online mindfulness intervention: A randomised waitlist-controlled trial
(Wiley, 2024) Baminiwatta, A.; Fernando, R.; Solangaarachchi, I.; Abayabandara-Herath, T.; Wickremasinghe, A.R.; Hapangama, A.
The high prevalence of psychological problems observed among healthcare workers (HCWs) during the COVID-19 pandemic called for interventions to safeguard their mental health. We assessed the effectiveness of a 6-week online mindfulness-based intervention in improving well-being and reducing stress among HCWs in Sri Lanka. Eighty HCWs were recruited and randomised into two groups: waitlist-control (WLC) and intervention groups. In the intervention, 1-hour online sessions were conducted at weekly intervals and participants were encouraged to do daily home practice. Stress and well-being were measured pre- and post-intervention using the Perceived Stress Scale and WHO-5 Well-being Index, respectively. One-way analysis of covariance was used to evaluate the effectiveness, in both intention-to-treat (ITT) and complete-case (CC) analyses. A significantly greater improvement in well-being occurred in the intervention arm compared to WLC on both ITT (p = .002) and CC analyses (p < .001), with medium-to-large effect sizes (partial η2 = .117-.278). However, the reduction in stress following the intervention was not significant compared to the WLC group on both ITT (p = .636) and CC analyses (p = .262). In the intervention arm, the median number of sessions attended by participants was 3. Low adherence to the intervention may have contributed to the apparent non-significant effect on stress.
Maternal mental health services in Sri Lanka: challenges and solutions
(Royal College of Psychiatrists, London, 2021) Hapangama, A.; Kuruppuarachchi, K.A.L.A.
Sri Lanka boasts of making significant strides in the indicators of maternal healthcare during the past few decades. However, these indicators mostly look only at the physical well-being of women. Lack of awareness regarding maternal mental health problems among grass-root level healthcare workers, poor integration of services, and the culture and stigma regarding perinatal mental disorders are barriers to improving services in maternal mental healthcare in Sri Lanka.
Measuring resilience among Sri Lankan healthcare workers: validation of the brief resilience scale in Sinhalese and Tamil languages
(Sage Publishing, 2023) Baminiwatta, A.; Fernando, R.; Gadambanathan, T.; Jiyatha, F.; Sasala, R.; Kuruppuarachchi, L.; Wickremasinghe, R.; Hapangama, A.
Resilience is the capacity for adaptation and “bouncing back” in the face of adversity.1,2 It protects against mental health problems such as depression, anxiety, and stress and improves well-being. 3 During the COVID-19 pandemic, there was a growing need for studies on protective factors in mental health, such as resilience, particularly among healthcare workers. 4 Psychometric assessment of resilience is a prerequisite for research in this area. A review of 19 resilience scales found a wide variation in their psychometric properties, with all of them posing some challenges. 5 However, the authors noted that the Resilience Scale for Adults, Brief Resilience Scale (BRS), and the Connor-Davidson Resilience Scale had the finest psychometric ratings. BRS may have an exceptional place in behavioral research because other resilience scales tend to assess resources that promote resilience rather than resilience itself. BRS is probably the only measure to assess resilience in its most basic meaning—the ability to “bounce back.” 2 Furthermore, among resilience scales, BRS is short and, therefore, would generate better response rates in research. As BRS was not available in local languages, its validation into Sinhalese and Tamil languages was needed to enable research on resilience in Sri Lanka. METHODS: Approval was obtained from the Ethics Review Committee. The procedure for questionnaire translation followed the recommendations of Beaton et al. (2000). 6 Firstly, BRS was translated into each local language (Sinhalese and Tamil) independently by two bilingual experts, and a consensus translation was prepared. The translated version was back-translated into English by two independent bilingual translators. They were compared with the original BRS for semantic, idiomatic, experiential, and conceptual equivalence by a group of experts comprising several Sinhalese- and Tamil-speaking psychiatrists, bilingual experts, and a methodologist. A few phrases in the original English version, such as “bounce back” and “snap back,” were replaced with conceptually equivalent phrases in the local languages. Face and content validity were discussed, and a consensus translation was prepared. After conducting a pre-test and cognitive debriefing with a purposive sample of 10 healthcare workers for each language, and further minor modifications, the translated scales were administered to 150 Sinhalese- and 110 Tamil-speaking healthcare workers (nurses, doctors, and other categories), after obtaining informed consent (see Table S1 for the sociodemographic profiles; the translated questionnaires are provided as supplementary files). Confirmatory factor analysis (CFA) was used to test the model fit for the one-factor structure of BRS, 2 using the following fit indices: comparative fit index (CFI), Tucker Lewis index (TLI), standardized root mean square residual (SRMR), and root mean square error of approximation (RMSEA). Depression, anxiety, and Stress Scale -21 (DASS-21) was administered to test expected inverse correlations with resilience. RESULTS: According to CFA, the six-item BRS formed a unitary construct, with satisfactory model fit for both the Sinhalese (CFI = 0.99, TLI = 0.99, RMSEA = 0.09, SRMR = 0.05) and Tamil versions (CFI = 0.98, TLI = 0.97, RMSEA = 0.14, SRMR = 0.07). Factor loadings of individual items ranged from 0.59 to 0.86 in the Sinhalese and 0.61 to 0.82 in the Tamil version (see Table S2 for item-level statistics). Cronbach alpha of the Sinhalese and Tamil BRS were 0.82 and 0.80, respectively, indicating good internal consistency. Removal of any single item did not significantly improve internal consistency. The Sinhalese BRS score had significant negative correlation with depression (r = –0.29, P = 0.002), anxiety (r = –0.27, P = 0.005), and stress (r = –0.20, P = 0.033), whereas the Tamil BRS score had significant negative correlation with anxiety (r = –0.18, P = 0.028) and stress (r = –0.25, P = 0.002) but not with depression. DISCUSSION: Our findings support the construct validity and internal reliability of the BRS as a measure of resilience. The one-factor structure proposed by the original developers 2 and replicated in subsequent studies 7 was observed in the present study. BRS has been previously translated and validated in several languages, including German, Polish, Spanish and Dutch.7–10 Similar to the observations in the original validation sample 2 and the Spanish validation, 7 resilience, as measured using BRS, showed significant inverse correlations with depression, anxiety, and stress in the present analysis. This provided further support for its construct validity through hypothesis testing. The absence of a significant inverse correlation of the Tamil BRS score with depression may be due to the comparatively small sample size available for the Tamil validation. Although our findings were based on healthcare workers, we expect the scale’s validity to extend to the general population. Thus, the Sinhalese and Tamil BRS can be used in future large-scale research on resilience in Sri Lanka. As high rates of mental health issues were reported among healthcare workers in Sri Lanka during the COVID-19 pandemic, 11 and the country is currently going through an unprecedented economic crisis, it is important to take measures to enhance resilience among Sri Lankan healthcare workers. The availability of a validated tool in both Sinhalese and Tamil languages would enable research on mental health and resilience among culturally-diverse populations in Sri Lanka, which would provide useful information to guide health policy development. Limitations of this study include the small sample sizes and the lack of test-retest reliability assessments to ascertain the temporal stability of the BRS scores.
Minimizing wait time for patients with mental health issues at an Emergency Department: An Australian experience
(Sri Lanka Medical Association, 2019) Hapangama, A.; Kojadinovic, V.; Katz, P.
INTRODUCTION & OBJECTIVES: Efforts have been made globally to re-structure care of patients with mental illnesses by shifting resources from institutionalized care towards the community. However, number of people at a given time with mental illnesses and lack of resources have placed heavy constraints on community psychiatry services resulting in patients with mental illnesses overcrowding at Emergency Departments (EDS). EDS across Victoria appear to struggle in order to deal with them. The Psychiatric Assessment and Planning unit (PAPU) at Maroondah Hospital, Victoria was established with one of its aims being the reduction of overcrowding and waiting time at its emergency department. METHODS; An audit was carried out based on the electronic medical records system and data was extracted regarding the total number of presentations with mental health needs, total number of admissions to PAPU and to see those admitted to PAPU meet the state-established performance goals during the financial year of 2017. RESULTS: Out of the 5636 patients who had presented to ED with mental health issues, 435 met criteria for PAPU and 304 (69.9%) had been assessed within 4 hours of them presenting to the ED. 228(75%) of had occurred between 0830 am and 5 pm. CONCLUSION: preliminary data show that PAPU appears to considerably lower the waiting time at the Maroondah